National Health Programs

National Health Programs

State Institute of Health and Family Welfare, Jaipur

Programs address to

Environment
NGCP
NWSSP

Host Agent
UIP RNTCP
HIV/AIDS
MAP
NFWP
NLEP
NPCB

SIHFW: an ISO 9001:2008 certified Institution 2

Mile stones
NRHM-2005
NHP-2002
NPP-2000

RCH-1996

UIP-1985
NHP-1983

Alma Ata-1978
Small pox eradicated-July 5, 1975

NFPP-1952
India Joins WHO-1948

HSDC-1946


Programs
NRHM-2005
NVBDCP-2004
NHP-2002
NPP-2000
NSPCD-1997-
(IDSP-2004)
RCH-1996
CSSM-1992
NACP-1987
UIP-1985
NGCP-1962 NIDDCP-1992
NFWP-1977
NPPVICB-1976
NCCP-75-76
NTCP-1962 RNTCP-1993
NFCP-1955
NLCP-1955
NMEP-1953
NFPP-1952

Program components
— Need
— Goals & Objectives
— Strategy
— Approach
— Activity
— Indicators
— Monitoring & Evaluation
— Financing


Major Programs
— National AIDS Control Program
— National Cancer Control Program
— National Diarrheal Disease Control Program
— National Filaria Control Program*
— National Family Welfare Program
— National Iodine Deficiency Disorders Control
Program
— National Leprosy Eradication Program


— National Malaria Eradication Program*
— National Program for Control of Blindness
& Visual Impairment
— National Reproductive and Child Health
Program
— National Program for surveillance Program
for Communicable diseases
— National Tuberculosis Control Program
(Revised)

(* Programs are merged into
National Vector Borne Disease Control Program since 2003-04)


Minor Programs

— National Mental Health Program
— National Japanese Encephalitis control Program*
— National Diabetes Control Program
— National Kala-azar Control Program*
— National Water Supply and Sanitation Program


National Family Welfare Program
(NFWP)


National Family Welfare Program

Ø 1951, 100% Centrally Sponsored, concurrent list
Ø First country in the world
Ø Family Welfare Dept.- created in 3rd FYP
Ø 4th FYP - integration of Family Planning services
with MCH services
Ø MTP Act introduced 1972


Approach
— 1st and 2nd FYP- “Clinical”
— 2nd FYP - “Target approach”
— 3rd FYP – “Extension & Education” approach
— 4th Plan - Post Partum scheme, reduce CBR to 32
— 5th Plan – NFPP replaced by NFWP, reduce CBR to
30
— 6th Plan - Net Reproduction Rate (NRR) of 1, family
size to 2.3
— 7th Plan - spacing methods, community participation
and promotion of MCH care


Approach
— VII FYP
?Area Development Projects
?India Population Project-VIII & IX
?India Population Project-VIII & IX
?Differential planning scheme
?Increasing involvement of NGOs
?UIP & CSSM
?TFA

IX FYP
Indicator If current If acceleration envisaged in Approach
trend Paper to the Ninth Five Year Plan is
continues achieved.

CBR 24/1000 23/1000
IMR 56/1000 50/1000
TFR 2.9 2.6
CPR 51% 60%
NNMR 35/1000
MMR 3/1000


— X FYP –
– Objectives:
?Reduction in the decadal rate of population
growth between 2001 and 2011 to 16.2%;
?Increase in Literacy Rates to 75 per cent
within the Tenth Plan period (2002 to
2007)
?Reduction of Infant mortality rate (IMR) to
45 per 1000 live births by 2007 and to 28
by 2012


X-FYP
ØPopulation Policy
ØNRHM
– IMR,MMR,TFR
– Unmet Needs- Increasing Contraceptive
choices
– Male involvement
– Social marketing
– Private sector involvement
– Infrastructure strengthen
– Involvement of PRI
– IEC
– Training SIHFW: an ISO 9001:2008 certified Institution 15

XI FYP
?Targets
?Reduce IMR to 28 and MMR to 1 per 1000
live births
?Reduce TFR to 2.1
?Provide clean drinking water for all by 2009
and ensure that there are no slip-backs
?Reduce malnutrition among children of age
group 0-3 to half its present level
?Reduce anemia among women and girls by
50% by the end of the plan
– Family planning insurance Scheme
– Jansankhya Sthirata Kosh

Goals: XI FYP
Ø Reducing MMR to 100
Ø Reducing IMR to 28
Ø Reducing TFR to 2.1
Ø Providing clean drinking water for all by 2009
Ø Reducing malnutrition among children of age
group 0–3 to half its present level.
Ø Reducing anemia among women and girls by 50%.
Ø Raising the sex ratio for age group 0–6 to 935 by
2011–12 and 950 by 2016–17.


Empowered Action Groups

Ø GOI constituted an EAG w.e.f. 20th March,2001
Ø To facilitate the preparation of area-specific
programs,
Ø With special emphasis on eight states
[Rajasthan, UP, Bihar, MP, Orissa,
Chhattisgarh, Jharkhand, Uttaranchal]


Role of the EAG

Ø Ensuring appropriate policy development at the
Centre,
Ø Provisioning for technical assistance to the
member States,
Ø Addressing issues of coordination between
member states and departments
Ø Deploying financial resources, as appropriate
and feasible.


Family Planning Insurance scheme
Ø To encourage people to adopt permanent
method of Family Planning
Ø Centrally Sponsored Scheme since 1981 to
compensate the acceptors of sterilization for the
loss of wages
Ø Implemented through ICICI Lombard General
insurance Company
Ø Compensation: (w.e.f-07.09.07)
Ø Compensation in case of adverse event (w.e.f.
January 1st, 2009)


Family Planning Insurance scheme:
Compensation: (w.e.f-07.09.07)
In Govt. facilities-
Cate Intervention Acc Moti Dru Sur Anes Sta OT Ref Ca
gory epto vato gs geo theti ff Ass res mp
r r n st nur tt. hm mgt.
se ent
High Vasectomy (all) 1100 200 50 100 - 15 15 10 10
focus Tubectomy(all) 600 150 100 75 25 15 15 10 10
states
Non Vasectomy (all) 1100 200 50 100 - 15 15 10 10
high Tubectomy(BPL, 600 150 100 75 25 15 15 10 10
focus SC/ST only) 250 150 100 75 25 15 15 10 10
states Tubectomy( APL
only)


In Pvt. facilities-

Category Type of operation Facili Motiv Total
ty ator
High Vasectomy (All) 1300 200 1500
Focus Tubectomy (All) 1350 150 1500
States
Non High Vasectomy (All) 1300 200 1500
focus Tubectomy 1350 150 1500
states (BPL+SC/ST)


Jansankhya Sthirata Kosh

Ø National Population Stabilization Fund -
registered as an autonomous Society
Ø Combination of government and civil society
Ø Working to promote innovations
Ø Promote initiatives which leverage the strength of
different economic and social sectors
Ø To reach out needy population groups


Ø Observation of World Population Day
Ø Prerna Awards at Dhaulpur and Jodhpur in
Rajasthan and Nabarangpur in Orissa
Ø Working with the Private Sector Medical
Specialists to enhance services for contraception.
Ø Induction of professional people [NGOs, CII,
FICCI, IASP, IPHA, IAP & SM, FOGSI etc]
Ø Material Development and display for IEC/BCC


Innovative Strategy under JSK
“Prerna”

“Prerna” provides reward for specific parenthood

Ø Girl’s marriage after 19 years - Rs.5000
Ø First birth after 21 years - Rs.7000 (girl)
Rs 5000 (boy)
Ø 3 years gap between first and second child with
sterilization of 1 parent after the 2nd child (Reward
of Rs.7000/ if it’s a girl child & Rs 5000/ if it’s a
boy)


Conditions for getting rewards
Ø Couple must belong to any of the 46 districts
identified
Ø Must belong to BPL category
Ø Preference given to younger couples
Ø Only those couples who have completed
registration of marriage and registration of the
birth of each child
Ø The award shall be given in form of Kisan Vikas
Patra in the name of Couple and will be given at
a public function


“Santushti”
Ø Motivate private gynecologists to perform 100
tubectomy/vasectomy, doctors are paid according
to already notified compensation rates (Rs 1500
per case)
Ø MOU is signed between the district CMHO and
private facilities
Ø Funding is provided by JSK through the Collector
and CHMO
Ø Initiated in Madhya Pradesh, Rajasthan and Orissa
Ø 64 MOUs and around 1600 sterilization operations
[until Aug 09]


Virtual Resource Centre (VRC)

Ø VRC is a virtual resource/documentation centre
Ø Provides access to films, posters, photos
Ø Subjects like anemia, gender, maternal and
infant mortality, sex ratio, adolescent health,
spacing etc.
Ø Media, Researchers, Students NGOs and
General public has access to it
Ø Inter-university and school level quiz
competitions


National AIDS Control Program


HIV/ AIDS

A Acquired must do something to
acquire
I Immune ability to fight disease
D Deficiency
S Syndrome cluster of symptoms
characteristic of disease
Ø First case: 1986
Ø National AIDS control program: 1987
Ø NACO: 1992

HIV/ AIDS prevalence criteria

Ø High: > 1% in Ante-natal women
Ø Moderate: < 1% in Ante-natal,
> 5% in STD/other high risk
behavior
Ø Low: < 1% in Ante-natal &
< 5% in STD/other high risk
behavior


Some facts

Ø One disease
Ø Two Viruses
Ø Three transmission modes-
• Sexual
• Vertical
• IV Drug/Blood


Ø Four interventions
• Communication
• Counseling
• Condoms
• Care of PLWA
Ø Five owe responsibility
• Individual
• Family
• Community
• Care providers
• Media


Facts – 2007
Source: Annual Report NACO-2008-09

People living with HIV/AIDS 1.8-2.9 million
Adult Prevalence – 0.34%
Males - 0.44%
Females - 0.23%
Prevalence:
Antenatal clinic HIV : 0.48%
STD clinic HIV : 3.6%
IDU HIV : 7.2%
MSM HIV : 7.4%
Female sex worker HIV : 5.1%

NACP Phase-I (1992-99)

Key Objective-
— Slow the spread
— Reduce- morbidity/mortality/impact


NACP-I Components:

— Strengthening management Capacity
— Promoting public awareness & comm.
Support
— Improving blood safety from 30 to 90% &
rational use
— Controlling STDs
— Building surveillance & clinical mgt. capacity

Key factors affecting project

— New program, little capacity to address
— Society & professionals unaware of HIV
— Difficult to identify, reach & cover risk group
— Linkages to STD/Tuberculosis inadequate
— Borrower’s & recipients non-familiarity with
project processing requirement
— Lack of ownership by States
— Lack of uniformity of process & infra-
structural support
— Delay in release of funds


NACP phase-II(1999-2004)
— Nov.9, 1999

— 100% Centrally sponsored

— 32 States/UTs & 3 Municipal Corporations

— Participatory Planning- NACO/State/NGOs
/Private sector/ stake holders-Approved by
Cabinet-August 26, 1999


NACP Phase-II: Key Objectives

• Reduce spread of HIV in India

• Strengthen India’s capacity to respond
to HIV/AIDS on a long term basis


NACP-Phase II: Objectives:
• Shift in focus (Awareness Behavior)
• Encouraging voluntary testing
• Support structured & evidence based
• Reviews & ongoing operational research
• Encourage Mgt. Reforms & Ownership
• Decentralization- Program delivery to be
-Flexible
-Evidence based
-Participatory
-Local base

NACP Phase-II : Components:

• Delivery of cost effective
interventions

• Strengthening capacity


NACP Phase- II Performance
Indicators
— HIV prevalence-5% in Maharashtra
3% in TN+AP+Manipur
& Karnataka
< 1% in other States

— Reduce blood borne transmission <1%

— Awareness level of 90% in youth & Rep.
Age group

— Condom use level of not < 90% among
high risk groups-CSWs.


India responds-Dec.2001
— 11 care &support centres
— 145 voluntary testing centres established
— 77 National Telephone help lines#1097
— 115000 mothers counseled, transmission
rate down to 9.6%
— National AIDS Control Policy
— National HIV Testing Policy
— National Blood Policy


National AIDS control policy
Aims at-
— Prevention through awareness about
implications & providing protection
measures
— Provide enabling social environment to
people & families with HIV/AIDS
— Improve services, for PLWA, in hospitals &
at home through community health care


AIDS Control strategy

— Program management
— Surveillance & Research
— IEC & Social mobilization through
NGOs
— Control of STDs
— Condom programming
— Blood safety
— Impact reduction


NACP-III (2006-2111)
Goals and Objectives

• Halt and reverse the epidemic

• Integrate Programs for prevention,
care & support and treatment


Phase III

Objective
Ø Prevent infections

Ø care, support and treatment to PLHA.

Ø Strengthen- infrastructure, systems and

human resources
Ø Strengthen the Strategic Information

Management System


Phase III

Specific objective
ØReduce new infection as estimated in the
first year of the program by:
• Sixty per cent (60%) in high prevalence
states
• Forty per cent (40%) in the vulnerable
states so as to stabilize the epidemic.


Strategy
— Targeted Interventions
— The Link Worker Scheme
— Preventive interventions for the general
population
— Sexually Transmitted Infections (STI)
Services
— Mainstreaming HIV for multi-sectoral
response
— Condom Promotion
— Blood Safety
— Other activities for Blood safety

Strategy

— Care, Support and Treatment PLHA
— Institutional Strengthening and Capacity
Building
— Strategic Information Management
— Monitoring and Evaluation
— Improving CMIS and overall Reporting
— HIV Sentinel Surveillance

Mainstreaming HIV

Ø Constitution of the State Councils on
AIDS (SCA)
Ø Greater Involvement of People Living
with HIV (GIPA) under NACP-III
Ø Mainstreaming with civil society
organizations


Blood Safety
Aims
Ø Ensure provision of safe and quality
blood
Ø Ensure reduction in the transfusion

Strengthening of Blood bank facilities
through:
• District level Blood Banks
• Blood Component Separation Units
• Blood Storage centres
• Blood Refrigerated Vans

Care, Support and Treatment for
People Living with HIV/AIDS (PLHA)

NACP III includes Comprehensive
management of PLHA with respect to
ØTreatment and prevention of
opportunistic
infection
ØART
ØPsychosocial support
ØHome based care
ØPositive prevention and impact
mitigation

The target for National ART program
Ø Free ART to 300000 adult, 40000
pediatric PLHA by 2012 through 250 ART
and 650 link ART centres.
Ø Achieve and maintain high levels of
adherence and minimize numbers lost to
follow up
Ø Involve inter sectoral partners, NGOs and
Private partners
Ø Provide comprehensive care, support and
treatment through 350 Community Care
centres by 2012

Monitoring and Evaluation

Ø Development of an integrated M&E Plan
for NACP-III
Ø Strengthening systems for better M&E
Ø Improving Component Specific M&E
– ART centres
– ICTC
– STI/RTI Reporting
– Community Care centres


HIV Sentinel Surveillance

Ø Surveillance in India was started from
1985
Ø NACO established in 1992, sentinel
surveillance for HIV/AIDS in India.


Objectives of HIV Sentinel Surveillance

Ø Determine the level of HIV infection
Ø Understand the trends of HIV
epidemic
Ø Understand the geographical spread
of HIV infection
Ø Provide information for planning the
Program
Ø Estimate HIV Prevalence and HIV
burden


National Vector Borne Disease
Control Program (NVBDCP)


National Vector Borne Disease
control Program (NVBDCP)

NAMP
NFCP
Kala-azar control Program
Dengue/Dengue Hemorrhagic fever and
Japanese Encephalitis (J.E.)
merged as NVBDCP


Malaria Control Program
Ø 1953 : NMCP launched
Ø 1958 : NMEP launched
Ø 1971 : Urban Malaria Scheme (UMS)
Ø 1976 : Resurgence with peak- 6.47M cases
Ø 1977 : MPO & PfCP
Ø 1979 : Centrally sponsored, 50:50 basis
Ø 1985 : 2 million cases
Ø 1991 : Peak in Pf cases
Ø 1994 : Epidemic: Eastern India & Western Raj
Ø 1995:Malaria Action Plan
Ø Sept.1997: EMCP
Ø Apr. 1999: NAMP
Ø 2004: NVBDCP


2000000 1869403 1915363 Malaria: India
1900000
1816569 Source: CBHI NHP, 2008
1800000 1780777
1700000
1600000 Cases
1500000 1508927 Deaths
1400000
1300000 1366517
1200000
1100000
1000000
900000
800000
700000
600000
500000
400000
300000
200000 1006
100000 949
0 963 1704
1331 8878
2003
2004
2005
2006
2007
2008*


Malaria: Cases Rajasthan
Source: CBHI NHP, 2008
57482

142738

55043
2003
2004
2005
2006
99529 2007
2008*

105022
52286


Malaria Situation in India

Total Cases (2008-09 Sept.):
India : 1075588
Rajasthan : 26787

Total Deaths (2008-09 Sept.):
India : 754
Rajasthan : Nil


Measuring Malaria

Human indices

i. Annual Parasite Index (API)
ii. Annual Blood Examination Rate
(ABER)
iii. Annual Falciparum Index (AFI)
iv. Slide positivity rate (SPR)
v. Slide Falciparum Rate (SFR)


Malaria Control

A. Management of cases
ØDiagnosis- Blood slide (Thick & Thin)
ØTreatment
i. Presumptive (With Chloroquine)
ii. Radical
iii. Mass drug administration (in areas
with API>5)
ØChemoprophylaxis


Malaria Control

B. Interruption in Transmission
Vector control:
1. Anti adult measures-
a. Indoor residual spraying
(IRS)
b. Space application
c. Genetic control


National Drug Policy: Malaria
2008
Ø Treatment-1:
a. chloroquine (25 mg/Kg fpr 3 days + Primaquine
(0.75 mg. /Kg for one day
Or
b. Artesunate (4 mg/Kg for 3 days)+sulpha
pyrimethamine (25/1.25 mg/ Kg single dose)
+Primaquine (0.75 mg /Kg single dose)
Ø Treatment-2:
Chloroquine (25 mg/Kg for 3 days+Primaquine (0.25
mg/ Kg for 14 days)
Ø Treatment-3:
Chloroquine (25 mg/Kg for 3 days)

Suspected (Clinically) Malaria Cases

Microscopy result

Available Not Available

Rapid diagnostic Kit
Falciparum Vivax Negative

Available Not Available

Treatment-1 Treatment-2 Faliciparum Negative
Take slide
Treatment 3
Treatment-1
Slide

Falciparum Vivax Negative

Primaquine 0.75 mg/kg single dose or ACT +
Primaquine in qualified areas Primaquine 0.25mg/kg for 14 days

Malaria Control Strategies
— Early Case Detection & Prompt Treatment
(EDPT)
— Vector Control
Chemical Control
Biological Control
— Personal Prophylatic Measures
— Community Participation
— Environmental Management & Source
Reduction Methods
— Monitoring and Evaluation of the Program


National Iodine Deficiency Control
Program


Problem Statement
— World’s single most significant cause of
preventable brain damage and mental
retardation.
— 261 million suffering from brain damage (10
million cretins)
— 130 countries, 13% of world’s
population.
• 9 million persons affected.
• 2.2 billion people live in ID areas
• 167 million at risk of IDD
• Goiter- 54.4 million

Problem Statement
• IDD mental/motor handicaps - 8.8 million
• 1984-86: ICMR multi centric study
• 14 districts in 9 States
• Goiter prevalence 21.1%
• Endemic cretinism : 0.7%

• India : 241 of 617 Districts are Goiter endemic
• 140 million people are estimated to be living in
goiter endemic regions
• 51% HH consuming iodized salt (State of World’s
Children, 2009-UNICEF)


Turning point of the program :
1983
— Questions asked by Mrs. Indira Gandhi
?What is Iodine Deficiency?
?Why should I be interested in National Goitre
Control Program (NGCP)?
?How is it going to contribute towards PM’s 20
point Program?


National Iodine Deficiency Control
Program


Program Developments

— 1962: NGCP launched
— 1984 : Policy of Universal salt Iodization(USI)
: Private sector to produce iodized salt
— 1992: NGCP renamed as NIDDCP
— 1995: Independent survey evaluation of USI in
MP, New Delhi and Sikkim
— 1997: sale and storage of common salt banned
— 1998-99: NFHS II
: 71% using iodized salt
— 13th Sept 2000: ban on sale of common salt
lifted by the GoI, States continued the ban

Goal :
To decrease overall IDD prevalence (goiter) to <5%
in the school children 6-12 years.

Objectives :
• Surveys to assess the magnitude of the IDD.
• Supply of iodated salt in place of common salt
• Resurvey after every 5 years to assess the
extent of iodine deficiency disorders and the
Impact of iodated salt.
• Laboratory monitoring of iodated slat and urinary
iodine excretion.
• Health education & publicity.

Spectrum of IDD

Fetus: Abortion, Still Birth, Congenital
Anomalies, Prenatal mortality, Infant
mortality, Neurological cretinism (mental
deficiency, deaf mutism, squint)
Neonate:Neonatal Goiter, Neonate
Hypothyroidism
Child and adolescent: Juvenile Hypothyroidism,
Impaired Mental function, Growth
retardation
Adult: Goiter, Hypothyroidism, Impaired mental
function

Classification of goiter

Grade 0: No palpable or visible goiter

Grade 1: A mass in the neck with
enlarged thyroid, palpable but
not visible

Grade 2: Swelling in the neck that is
palpable as well as visible


Strategy

A. Essential components of IDDCP
– Ensuring availability of iodized salt
?30 PPM at production level
?15 PPM of iodine at consumer level
– Awareness generation to increase
consumption level up to 90%
– Iodized salt is most economical
convenient and effective means of mass
prophylaxis


B. Iodine monitoring through lab
?Iodine excretion determination
?Determination of iodine in water, soil and
food
?Determination of iodine salt

Fortified salt with iron and iodine neonatal
hypothyroidism is a sensitive point to
environmental iodine deficiency

C. Manpower training
D. Mass communication


Comprehensive Action Plan

— Creating Demand for iodized salt in
Community
— Improving Monitoring of quality of iodized salt
— Increasing outlets and access to low cost
adequately iodized salt
— Improving iodized salt production
— Advocacy with Policy Makers and Program
Managers


Initiatives - Rajasthan

— Reinforce sampling of salt under PFA
— Training of concerned paramedical and
health staff at various level with the help
of UNICEF
— Component will be included in School
Health Program
— District nodal officer are directed to send
regular reports to IDD cell


— Strengthening of IDD monitoring lab.
— Monitoring included in IDSP
— 10 Districts has been taken for developing
labs in CM&HO’s office for examination of
Iodized salt
(Bikaner, S.Ganganagar, Barmer, Sirohi,
Chittorgarh, Banswara, Jhalawar, Bhartpur,
Nagaur, Alwar)


Achievements

• Salt manufacturing license issued to 930 units
• 26 States have totally banned non-iodized salt
• 29 States and UTs have established IDD cells
• Intensive IEC campaigns
• Standards for iodized salt
• National reference laboratory set up
• Ban on sale of non iodized salt


National Program for prevention of
Visual Impairment and Control of
Blindness


Global Scenario
— 314 million visually impaired, 45 million blind.
— Aged and females are more at risk
— 87% of visually impaired in developing countries.
82% of visually impaired are 50+
— Age-related impairment is increasing.
— Cataract - leading cause
— Refractive errors correction could give normal
vision to >12 million children (ages five to 15).
— 85% of all visual impairment is avoidable


Chronological developments

1963: Started as National Trachoma Control
Program
1976: Renamed as National Program for prevention
of Visual Impairment and Control of
Blindness(100% Centrally Sponsored)
1982: Blindness included in 20-point program

“2020-the right to sight”.


Objectives
Ø Reducing the Blindness prevalence from 1.4%
to 0.3% by 2020
Ø Provide high quality of eye care
Ø Expand coverage of eye care to the affected
population & under-served areas
Ø Reduce backlog of blindness
Ø Develop institutional capacity for eye care
services


Strategies
Ø Decentralized DBCS
Ø Active screening of population above 50 years of
age.
Ø Involvement of voluntary Organization
Ø Participation of community and PRI
Ø Development of eye care services and
improvement in quality of eye care.
Ø Screening of school children
Ø Public awareness
Ø Specific focus on illiterate women in rural areas.
Ø To make eye care comprehensive


Indicators:

— Cataract operation in bi-lateral blind.
— Cataract surgery in female.
— Cataract surgery in SC/ST population.
— Cataract surgery in different facilities.
— Cataract surgery in different age groups.


Initiatives (2009-10):
— Free surgery for cataract cases in rural areas.
— Free transportation for patients.
— Free medicine for all types of eye ailments.
— Free spectacles for post operative care.
— Free spectacles for poor school students.
— Treatment of backlog cataract cases.
— All schools would be covered for SES.

Initiatives (2009-10)
• Vit- A supplementation and immunization
coverage.
• Modern treatment at Medical College and DH.
• one Eye Bank & 2 Eye Donation Centres
• Establishment of one RIO,Cuttack.
• ASHA: be trained and assigned to create
awareness. incentive of Rs 175/- per cataract
case, out of the fund earmarked under Cataract
Operation.
• Contractual Ophthalmology Assistants created


Implementing agencies
District Blindness Control Society (DBCS)
Composition
Chairman : District Collector
Vice chairman : Chief Medical & Health Officer
Members : Medical Superintendent of District hospital
District Education Officer
Representatives of NGOs
President of IMA
Ophthalmic surgeon of Mobile surgical unit
An eminent practicing Ophthalmologist
Member secretary : District Blindness Control Coordinator


Functions of DBCS

Ø Plan, Implement and Monitor
Ø Draw list of voluntary agencies/ private
hospitals/ NGOs
Ø Coordination with Health & other
departments
Ø Raise funds and monitor use of funds


Achievements

Year Target Achievement % Surgery
with IOL
2002-03 4000000 3857133 77
2003-04 4000000 4200138 83
2004-05 4200000 4513667 88
2005-06 4513000 4905619 90
2006-07 4500000 5040089 93
2007-08 5000000 5404406 94
2008-09 6000000 192805 -

National Leprosy Eradication Program


National Leprosy Eradication
Program
— 1955 -NLCP
— 1970s -Multi Drug Therapy. Dapsone treatment
continued.
— 1982 -MDT came into use from 1982,
— 1983 –NLEP
— 1993-2000- The 1st phase of WB supported
NLEP implemented
— 1998-2004:Modified Leprosy Elimination
Campaign
— 2005 - India achieved elimination National Level.


NLEP: phased approach
achievements

— 1st phase(1993-1994)- prevalence rate reduced
24 (1992) to 3.7/10,000

— 2nd phase (2001-02 to 2003-04) –
Decentralization, integration, Elimination

— PR – 0.84 /10,000 pop. (March 31, 2006)
(Elimination-1/10,000)


Case Load: 31 Dec.2005

5%
5%
Orrisa
4%
Chattishgarh
Jharkhand
40%
Uttar Pradesh
22% Bihar
West Bengal
Other

12%
12%

6 states(41% pop. and 61% case load) with PR >1/10000-March31, 2006


30
Leprosy trend – PR & ANCDR
Source : MoHFW
25.9
25

20
PR
ANCDR
15

10
8.4 7
5.5 5.9
5.9 5.3 4.4
5 4.9
3.7 4.2 3.3
3.2 2.3
2.4 1.43
1.3
0 0.95
1991 1995 2000 2001 2002 2003 2004 2005 2006

Objectives
Ø Render all case non-infectious in shortest
time by:
• Early detection & treatment
• Interrupting transmission
Ø Prevent deformities
Ø Eradicate Leprosy
Ø MDT throughout
Ø Prevalence-<1/10000 by 2002


Strategy

Ø Decentralization of NLEP to States & Districts
Ø Integration of leprosy services with General
Health Care System
Ø Leprosy Training of GHS functionaries
Ø Surveillance for early diagnosis & prompt
MDT, through routine and special efforts
Ø Intensified IEC using Local and Mass Media
approaches
Ø Prevention of Disability & Care


Elimination Strategy

— Strategic Plan of Action (2004-05)
— Focused Leprosy Elimination Plan (FLEP-
2005)
— Intensified Supervision And Monitoring
— Modified Leprosy Eradication Program
(1997)


Strategic Plan of Action (2004-05)
— Intensified focused action in 72 districts (PR > 5)
and 16 moderately endemic districts with more
than 2000 leprosy cases detected during 2003-04.

— Increased efforts put on IEC, Training and
Integrated Service Delivery in 86 medium priority
districts.

— Intensified IEC through Leprosy Counseling
Centres in 836 blocks (PR > 5)


Strategic Plan of Action (2006-07)
— Provision of quality services with
— proper referral for management of reactions,
— complications and correction of deformity
— in districts with PR > 1
— 29 districts and 433 blocks
— Activities proposed:
– Experienced district nucleus staff
– Vehicle
– Orientation for all the PHC Medical Officers
– Situational analysis within the district
– IEC , supervision and monitoring


Focused Leprosy Elimination Plan
(FLEP-2005)
— 42 high priority districts with PR > 3/10,000 located
in 7 endemic states.
— Increased efforts put on IEC, Training and
Integrated Service Delivery
— In 552 blocks (PR > 3) as on 31.03. 05, a two
weeks long Block Leprosy Awareness Campaign
(BLAC-II) through Intensified IEC and Leprosy
Counseling Centres at PHC level during the period
Sept.-Oct. 2005. M.Os reoriented


Modified Leprosy Eradication
Program (1997)
In order to address these challenges a few
areas were identified for intensive efforts.
These are-
ØTraining
ØIntensified IEC
ØDetection and immediate MDT


Approach

ØPrevalence based categorization
– Endemic : >5/1000
– Moderate : 3-5/1000
– Low : <2/1000
ØPlan of Action
– Preparatory phase
– Intensive phase
– Maintenance phase


Treatment
— MDT since 1982
— Rifampicin, clofazimine and dapsone
— Single dose of MDT kills 99.9% of leprosy
germs.
— Free-of-cost on all working days at all SC,
PHC, Govt. Dispensaries and Hospitals


Issues in treatment with Multi Drug
Therapy (MDT)

ØPrioritize (based on resources)
• Multibaciliary
• Paucibacilliary resistant to Dapsone
• Other Paucibacilliary
ØDelivery
• Adequate, Efficient, Flexible
• Referral
• Integration with primary care


Challenges

Ø Further simplify and shorten the regimen
Ø Abolish classification for treatment purposes
Ø Identify areas and communities not yet
covered
Ø Actively change the negative image of leprosy
Ø Focus more on analysis of detection trends
than on prevalence
Ø Develop an integrated community-based
strategy for rehabilitation


States and Districts according to endemicity levels
have been categorized and accordingly action
plan developed for-
Ø8 States with prevalence rate less than 5/ 10000
with
– Active case finding
– Promoting self reporting (Voluntary
reporting by cases-VRC)
– IEC & Training


Ø 14 States with prevalence rate 1-5/10000
– VRC
– Staff training &IEC
– Detection of paucibacilliary cases

Ø 13States with prevalence rate less than
1/ 10000
– Intensified IEC
– Detection of paucibacilliary cases


Revised National Tuberculosis
Control Program (RNTCP)


Revised National Tuberculosis
Control Program (RNTCP)
Issues in Tuberculosis:
Ø Case finding-Access to/ Availability of,
sputum microscopy
Ø Treatment-continuity, regularity &
compliance
Ø Drug resistance-MDR-TB (Every one who
breathes should be concerned)
Ø Dual Epidemic-HIV/AIDS & Tuberculosis.


Chronological Developments
Ø 1956-61:
ØTuberculosis Research Center at Chennai (1956)
ØNational Tuberculosis Institute established at Bangalore
(1959)
ØDistrict Tuberculosis Program (1961)
Ø 1962: National Tuberculosis Control Program (NTCP)
Ø 1975:Tuberculosis included in 20-point Program
Ø 1993: Pilot phase of RNTCP
Ø 1998: Stop TB initiative
Ø 1999: RNTCP -second largest program in the World
Ø 2003:>900,000 cases on treatment- largest cohort of
cases,

National Tuberculosis Control
Program (NTCP)
— Domiciliary treatment
— Use of a standard drug regimen of 12-18
months duration
— Treatment free of cost
— Priority to newly diagnosed patients, over
previously treated patients
— Treatment organization fully decentralized
— Efficient defaulter system/mostly self-
administered regimen
— Timely follow up

NTCP: Punctuations

— Managerial weakness,
— Inadequate funding,
— Over-reliance on x-ray,
— Non-standard treatment regimen,
— Low rates of treatment completion,
— Lack of systematic information on
treatment outcomes.


RNTCP-Goals

ØTo cure at least 85% of new smear
positive cases of Tuberculosis

ØTo detect at least 70% of sputum
positive cases after reaching 85%
cure rate


Strategy:
Directly Observed Treatment with
Short course Chemotherapy (DOTS)

Ø Political& Administrative commitment.
Ø Good Quality diagnosis
Ø Good Quality drugs
Ø Right treatment administered rightly
Ø Systematic Monitoring and
Accountability


DOTS Strategy interventions
Ø Case detection
Ø Adequate Drug supply
Ø Short Course chemotherapy given under
direct supervision.
Ø Systematic Monitoring and Accountability
Ø Political will & Advocacy
Ø System rather than Patient – Accountable
for Drug compliance


Achievements under RNTCP
(2007-08)
— Treatment success rates tripled from 25%
to 86% in 2008
— NSP CDR of 70% (2007) and 72% (2008)
— TB death rates reduced from 29% to 4%
— TB mortality reduced from 42 in 1990 to
28/100,000 population in 2006 (WHO Global TB
Report 2008).
— The prevalence of TB reduced from 568 in
1990 to 299/100,000 population by 2006
(WHO Global TB Report, 2008)


Performance: 2007-08
(source TB India 2009)

— No. of suspects examined 6817390
— No. Of smear positive diagnosed : 911823
— Percentage of smear positive among
suspects: 13%
— Registered for treatment: 1517333


Performance: 2007-08
(source TB India 2009)

— Annual Case detection rate : 132
— New smear+ patients reg. For treatment:
616016
— 3 month conversion rate of new smear
positive patients : 90%
— Cure rate of new smear positive patients :
84%
— Success rate of new smear positive
patients : 87%


RNTCP performance (Q4 2008)

Suspects examined: 1.65 million
Sputum +ve : 207144
Registered for Treatment:351593
New S+ve case detection rate: 67%


Treatment regimen under RNTCP

— Category-I
– New sputum smear positive
– Seriously ill sputum -ve
– Seriously ill extra pulmonary



— Category-II
– Sputum smear +ve relapse
– Sputum smear +ve failure
– Sputum smear +ve treatment after
default



— Category-III
– Sputum smear –ve not seriously ill,
– Extra pulmonary not seriously ill


Category Intensive phase Continuation phase
I 2 (HRZE) 3 4 (HR) 3
II 2 (HRZES) 3 5 (HRE) 3
+
1 (HRZE) 3
III 2 (HRZ) 3 4 (HR) 3
The figures outside the bracket refer to number of
months while those after the bracket indicate number
of doses per week


Organization structure
Health Minister

Health Secretary DGHS

Add. Secretary

Joint Secretary DDG (TB)

CMO RNTCP
TB
NGOs Consultants
Specialist
CMO CMO Deputy
Electronic
Drug Training Director (Adm.) Connectivity
SIHFW: an ISO 9001:2008 certified Institution
cell 130

Organization structure : state Level
Health Minister

Health Secretary DMHS

Special State TB Cell STO, Deputy
Secretary STO, MO, Acc., IE
C, Off., SA, DEO
Nodal Point for Dist. TB Centre DTO, MO-
TB control DTC(15%), LT, DEO, Driv
1/0.5 m (0.25 m in Hilly er
Tuberculosis MO-TC, STS, STLS
/difficult/tribal area) unit
1/0.1 m (0.05 m in Microscopy MO, LT (20%)
hilly/difficult/tribal area) Centre
DOT Provider –
0.25 m (TC), 0.005 DOT Centre MPW, NGO
m (SC) SIHFW: an ISO 9001:2008 certified Institution PP,Comm Vol
, 131

Emerging issues
Ø MDR-TB
Ø TB and HIV
Ø XDR-TB
Ø NGO Involvement
Ø Role of Medical Colleges
Ø Private sector involvement
Ø Participation of corporate sector
Ø Pediatric TB


Impact of the program
Ø TB mortality has reduced from 42/100,000
population in 1990 to 28/100,000
population in 2006 (WHO global TB report
2008).
Ø Prevalence of TB has reduced from
568/100,000 population in 1990 to
299/100,000 by the year 2006 (WHO
global TB report 2008).
Ø Repeat population surveys conducted by
TRC indicate an annual decline and
prevalence of disease by 12%

Terms used under RNTCP
— New case: A patient with sputum smear
+ve and who never had taken anti-
tubercular drugs for less than 4 weeks
— Relapse: A patient treated and declared
cured in past and now returns with
sputum +ve smear.
— Failure:A patient on anti-tubercular
treatment who remains or becomes
sputum positive after 5 months or later
during Short Course Chemotherapy.


— Cured: S+ve patient who completed treatment
and had negative smear on two occasions
(one immediately after treatment completion).
Initially S-ve who received full course , or a
S+ve who completed treatment with S-ve at the
end of initial phase but no or only one
negative smear during continuation and none
at the end
— Transfer in: Patient recorded and registered
in one area and transferred into another area
for completing treatment
— Transferred out: Patient transferred to
another area register.


Scheme of Evaluation of RNTCP:
Objectives-

— To validate the reported cure rates for
last quarter
— To assess program performance and
Logistics & Financial Management
— To give recommendations for improving
quality of Recording & Reporting
— To give recommendations for improving
performance


Evaluation of RNTCP:
Internal Evaluation Team-
— State TB Officer
— STDC Director (in states where STDC
exists)
— DTO of District other than one being
evaluated
— One WHO consultant of District not being
evaluated
— One WHO consultant of District other than
one being evaluated
— DTO & RNTCP staff of district being
evaluated

Evaluation of RNTCP: Selection of
Districts

— Frequency- Quarterly
— 2 Districts
?One with good performance
?Second with poor performance


Selection of Microscopy centres-

— Total of 5 MCs
?MC in DTC
?2 MCs from MCs that are examining
higher no. of TB suspects from the
enlisted 4, randomly
?2 MCs randomly from all the remaining
enlisted MCs


Selection of DOT centres-
— DOT centres in each of the 5 MCs
— 5 other DOT centres like-
?Attached to medical college
?STDC
?ESI
?Railways
?NGOs
?Private sector
?Aanganwadi
?DOT centres with 50+ patients

Selection of Patients-
42 Patients

36 NSP 6 others
2 patients who
are not NSP
30 NSP from those 6 from DOT from DOT centre
registered in last 2 quarters centres in in DTC and 2
DTC & 2 selected MCs
(6 from each of the 5 MCs
selected MCs) 1 NSP in IP phase and
1 with just finished IP
From each centre

Data Collection-Instruments

— Basic information of District
— Form 1- for review of recording &
Reporting
— Form 2-for interviewing DTO & his team
— Form 3-for reviewing MCs
— Form 4-for reviewing DOT centres
— Form 5-for interviewing patients &
checking consistency of records between
TB Register, Lab. Register and treatment
cards of 36 cases

Data Collection-Instruments

— Form 6- for consistency of records
between TB Register, Lab. Register and
treatment cards of NSP Patients where
outcome records are available
— Form 7-for summary of selected indicators
— Form 8-for non NSP Patients
— Form 9-for observations at TU
— Form 10-for recording overall
observations


Reporting results of Internal
Evaluation:
To Central TB division-
— Form no. 1, 7, 10 just after IE by e-mail.
— Hard copy within 2 days
— Form 1, 2, 6, 7, 8, 9 10 (one copy each)
— Form no. 3 -5 for 5 MCs
— Form no. 10 -10 for 10 DOT centres
— Form no. 5 – 5 copies


National Cancer Control Program


Cancer : India

— 8-9 lakh cases every year
— 25 lakh cases at any point of time
— 4 lakh deaths every year
— 40% cancers related to tobacco use
— Cancers – oral, lungs, cervix, breast account
for 50% deaths


National Cancer Registry Program
(NCRP)

• Initiated 1982 by ICMR
• Gives magnitude and patterns of cancer
• Types of registries
v Population Based Cancer Registry - 21
v Hospital Based Cancer Registries - 6


Goals & objectives of NCCP

— Primary prevention by health education
— Secondary prevention i.e. early detection and
diagnosis
— Strengthening of existing cancer treatment
facilities
— Palliative care in terminal stage of the cancer.


Evolution of NCCP
1975-76: National Cancer Control Program
launched
1984-86: Strategy revised and stress laid on
primary prevention and early detection of
cancer cases.
1991-92: District Cancer Control Program
started
2000-01: Modified District Cancer Control
Program initiated
2004 : Evaluation of NCCP by NIHFW
2005 : Program revised after evaluation


National Cancer Control Program
1975-76

Goals & Objectives

— Primary prevention of cancers by health
education
— Secondary prevention by early detection
and diagnosis of cancers,
— Strengthening of existing cancer treatment
facilities
— Palliative care in terminal stage cancer.


Intervention aimed at Determinants
— Tobacco
– Education- School/ addicts/ women
– Legislation- Sale/ Advertising/ public place smoking
– Taxation
— Diet
– Restrict-Fat/ nitrites/Afflatoxins/Additives/ oil
reheating
– Encourage- Fiber/Fruits/ Vegetables
— Sexual practices
– Delay age of marriage/ stick to one/ less no. of
children/ BF
— Occupation & environment
– Legislation/ Safety measures
— Infective agents
– Vaccination/Safe Sex

Service delivery in Cancer control

— District Cancer Control societies- structure
– District Collector
– CM & HO
– Rep. of Health services/Med. Colleges/
RCC/ NGOs
— Role-
– Fund generation
– IEC/ Early detection/ Screening/
Palliative care


Area Cancer Agency Approach Objectives Outcome
Pri. Prev. TRC People Education/ Reduce Reduce
NGOs Media tobacco use Incidence &
by 30% mortality
Screening Cervix Hlth. One pap at Screen Reduce
Services 40 yrs./ pap 80%of incidence
for high risk eligible by 50% in 5
yrs.
Early Oral cavity Doctor/ Oral self Detect 80% Reduce
detection Breast Paramedic. exam./ in early mortality
BSE stage by30%
Treatment Oral MC Surgery Effective Reduce
cervix Local RT treatment mortality by
breast trained 30%
doctors
Palliative All HW/People Ensure Community Quality
incurable availability care death


Services under NCCP-
PHC

— Health education
— Health promotion
— Home care
— Early detection
— Palliative care and pain relief


District level

— Health Promotion
— Home Care/
— Early Detection
— Pain Relief/Palliative Care
Treatment of common cancers
— Histopathology
— Endoscopy


Medical college without Oncology
unit
— Home Care
— Early Detection
— Pain Relief/Palliative Care
— Treatment of common cancers
— Training of medical
officers/paramedical personnel
— Preventive oncology-early detection/
Registration/ mobile units
— Radiotherapy with cobalt-60 units


Medical college with Oncology unit

— Diagnosis and staging by clinical/
histopathological/ biochemical/
radiological/ endoscopical/ immunological/
isotope
— Treatment-Radiotherapy/ surgery/
chemotherapy/ radiation
— Training of Med. /Paramedical
— Maintain hospital based registry


Regional cancer centre
— Home Care
— Early Detection
— Pain Relief/Palliative Care/Comprehensive
Cancer treatment
— Organize screening Program/Cytology
training/
— Basic and applied research/Training of all
categories of personnel
— Cancer Registries
— Epidemiology


Existing Schemes under (NCCP)
June 1, 2008

— Recognition of New Regional Cancer Centres
(RCCs)
— Strengthening of existing Regional Cancer
Centres
— Development of Oncology Wing
— District Cancer Control Program
— Decentralized NGO Scheme


Achievements

— Regional Cancer Centres: 27 RCC,
including 6 NGOs
— Oncology wing: 246 institutions with
radiotherapy facilities
— District Cancer Control Program: 28
districts
— IEC Activities: health magazine ‘Kalyani’


Achievements

— National Cancer Awareness Day
— Onconet- India: Telemedicine Services
including tele-consultations, tele-referral, tele-
pathology etc
— Membership of International Agency for
Research on Cancer :India has become a
member


New initiatives

— Logistics- Pap smear kits/Can scan software
— Outreach activities by medical colleges
— Training
— Supply of Morphine
— Telemedicine and supply of computer
hardware and software.
— IEC activities.
— Modified District Cancer Control Program
— National Cancer Awareness Day
— Training of cytopathologists and
cytotechnicians


Modified District Cancer Control
Program

— 4 States-UP/TN/Bihar/WB
— 60 Blocks
— 30 Doctors
— 12 lac women(20-65 Yrs.)
— Health education about-general ailments,
cancer prevention and early detection
besides 'Breast Self Examination' was
imparted


Global WHO Cancer Control
Strategy

— People-centered
— Equity
— Ownership
— Partnership & Multi-sectoral approach
— Sustainability
— Integration within broad framework of
delivery
— Evidence based strategy


National Mental Health Program


Mental Health: Problem Statement

Mental Disorders
— 6-7% of population
— 12% of Global Burden of Disease (GBD)
— 20% of world's children and adolescents
— One child psychiatrist for every 1-4M
— 800,000 people commit suicide every year,
86% of them in low- and middle-income
countries.
— Mental disorders-risk factors for CD and NCD


— No Mental Health Policy
— No data collection system
— Mental health disorders
• Schizophrenia
• Bipolar disorder
• Organic psychosis
• Major depression


Mental Health Resources: India
(per 10,000 population)

— Total Psychiatric beds: 0.25
— Psychiatric beds in mental hospitals: 0.2
— Psychiatric beds in general hospitals: 0.05
— Psychiatric beds in other settings: 0.01
— No. of Psychiatrists: 0.2
— No. of Neurosurgeons: 0.06
— No. of Psychiatric Nurses: 0.05
— No. of Neurologists: 0.05
— No. of Psychologists: 0.03
— Number of Social Workers: 0.03
(Source: Mental Health Atlas, 2005, WHO)


• National Mental Health Program, 1982,
re-strategized 2002
• 28 crore (IX FYP), 190 crore (X FYP),
1000 crore (XI FYP)
• District Mental Health Program 1995
• Synchronization with NRHM



• Legislation
• Mental Health Act , 1987
• Juvenile Justice Act, 1986
• The Persons With Disabilities (Equal
Opportunity, Protection Of Rights And
Full Participation) Act, 1995
• Narcotic Drugs and Psychotropic
Substances Act (Amended 2001)


Objectives

• Ensure availability and accessibility of
minimum mental health care for all
• Encourage mental health knowledge and
skills
• Promote community participation in
mental health service development and to
stimulate self-help in the community.


Strategies

— Expansion of DMHP to 100 districts all
over the country.
— Modernization of Mental Hospitals.
— Up-gradation of Psychiatry wings of Govt.
Medical Colleges/General Hospitals.
— IEC Activities.
— Research & Training in Mental Health for
improving service delivery


District Mental Health Program

DMHP – 123 districts
Upgradation of Psychiatric wings of 75
Government Medical Colleges/General
Hospitals
Modernization of 26 Mental Hospitals.


Components
— Establish Centres of Excellence in Mental
Health by upgrading and strengthening of
mental hospitals
— Provide impetus for development of
Manpower in Mental Health
— Spill over of 10th Plan schemes for
modernization of state run mental hospitals
and up gradation of psychiatric wings of
medical colleges/general hospitals.
— Counseling in schools, colleges, work place


Components
— Research-huge gap needs to be addressed
— IEC-remove stigma attached to mental
illnesses.
— NGOs and Public Private Partnership for
implementation of the Program to increase
outreach of community
— Monitoring Implementation & Evaluation


Thank You

For more details log on to
www. sihfwrajasthan.com
or
contact : Director-SIHFW
on

sihfwraj@yahoo.co.in

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